Audioconference Registration Form

AUDIOCONFERENCE REGISTRATION FORM

Name: __________________________________	Address_____________________________
Title:____________________________________	___________________________________
Organization:______________________________	Phone Number:_______________________
E-mail Address:__________________________	Fax Number: _________________________

Registrant Type:

____ State Legislator

____State Legislative Staff

____Government

____University

____Union

____Small Non-Profit w/budget less than $1 million

____Large Non-Profit w/budget more than $1 million

____Business and all others

_______ Yes, I will attend " Strategies for Preventing the Abuse and Neglect of Infants and Toddlers," on Wednesday, January 7th, 2004 from 1:00 p.m. to 2:30 p.m. ET

If you or your colleagues would like to participate in the audioconference, please complete this form and fax it back to 303-364-7811 or email to registration@ncsl.org or register online! Registration is free!

You will receive an email confirmation, a WEB ROOM NUMBER and TELECONFERENCE PASSCODE upon receipt of this registration form and a link to the audioconference log on instruction page. You will also receive email reminders in advance of the audioconference date.

QUICK SURVEY

Please briefly describe one major concern you have regarding child abuse prevention in your state.

____________________________________________________________________

What impact will your state's current fiscal situation have on child abuse prevention programs?

____________________________________________________________________

What can NCSL provide state legislatures to assist you in your child abuse prevention efforts?

______________________________________________________________________

THANK YOU!

For additional information, contact Nina Williams-Mbengue at 303/859-1559 or email to nina.mbengue@ncsl.org.